Berlowitz Bercovitz As a library, NLM provides access to scientific literature. Cohen This review and analysis provide a context for how 9 accompanying papers in this supplemental issue of The Gerontologist fill identified evidence gaps and provide evidence for future practice and policies that aim to transform nursing home culture. Burgess The law set out comprehensive residents' rights, it described residents' rights to quality of life as well as quality of care, it called for comprehensive assessments and care plans based on those assessments, and much more. M. Schnelle Federal government websites often end in .gov or .mil. If you aware of an individual who resides in a nursing home or assisted living, that are dealing with a violation of their personal rights. lems still exist in some of our Nation's nursing homes. S. Review of the Nursing Home Reform Act (NHRA) of 1987. L. W. Also, the culture change train has left the station, and so what is the role of research in examining and promoting optimal changes to the culture of care? L. W. Regulation change and new demands from the market have forced nursing homes to adapt. Avorn J, Soumerai SB, Everitt D, Ross-Degnan D, Beers MH, Sherman D, et al. S. M. RE>OON/_`%Q8RS?q&cIT+PV[/f^g//@f@J3x@':$XlTrB9:* Consumer statement of principles for the nursing home regulatory system. <>14]/P 19 0 R/Pg 201 0 R/S/Link>> M. T. Certified Ombudsmen are indispensable in ensuring that all facilities meet mandated, legal standards for every person requiring long term care. Accessibility C. The Nursing Home Reform Act of 1987: A Policy Analysis. Recognizing that existing studies do not provide adequate guidance on the processes to implement culture change and their related outcomes, Elliot, Cohen, Reed, Nolet, and Zimmerman (2014) identify specifically which domains of culture change have been adopted, and in what combinations, by nursing homes identified by national leaders. endobj M. A 178 0 obj Jacobson Delving more deeply into one component given the potential costs associated with physical improvements to make nursing homes more homelike, Miller, Cohen, Lima, and Mor (2014) explore how a states Medicaid capital reimbursement policy is associated with a nursing homes physical environment. J. The Nursing Home Reform Act became law 20 years ago. The heart of the Long Term Care Ombudsmen Program is the team of certified Ombudsmen who are empowered to resolve issues surrounding the care and quality of life for people living in nursing homes and assisted living facilities. 195 North 1950 West The other articles in this supplement address some of the methodological challenges and knowledge gaps identified in this review. 1-888-421-1100 Email: agingservices@utah.gov, HotlinesAbuse/Neglect of Seniors and Adults with Disabilities N Lubin (. Beverly The supplemental issue of The Gerontologist entitled Transforming Nursing Home Culture: Evidence for Practice and Policy seeks to expand the evidence base related to nursing home culture change by synthesizing existing literature and providing new information of special relevance to policy and practice. Recommendations for regulation soon followed, including the 1986 Institute of Medicine Report Improving the Quality of Nursing Home Care that promoted better care and emphasized the home as opposed to the nursing component of nursing home care (Vladeck, 2003). This supplement also explores how federal policies or statewide efforts can support nursing home culture change initiatives. J. L. This network gave birth to the name culture change. It gained steam in 2005, at the St. Louis Accord meeting of 400 long-term care leaders, including those from the Centers for Medicare & Medicaid Services (CMS) and State Survey and Certification Agencies; their involvement was particularly important, given that policies and regulations can serve to either promote or impede the movement (Rahman & Schnelle, 2008). In 1983, the US Congress asked the Institute of Medicine of the National Academy of Sciences to make recommendations for improving the quality of care in nursing homes.8 The 1986 report highlighted the substantial evidence of appalling care, including documentation of neglect and abuse that had led to premature death, permanent injury, and unnecessary fear and suffering.9 While recommending high quality care designed to improve wellbeing, the Institute of Medicine report recommended specifically that fewer psychotropic drugs should be used. E. National Library of Medicine Berlowitz http://www.uthca.org, Utah Assisted Living Association: http://www.aboutassistedliving.org/, Utah Health Care Associaion: Though the Misuse of Drugs Act covers details on the prescription of controlled drugs,23 the only legislative attempt aimed at changing prescribing behaviour in the United Kingdom was the limited list, which tried to counter rising drug costs but did not have a dramatic impact on patients and doctors choice of drugs.24,25, The United Kingdom may be better suited to an approach that focuses on achieving quality prescribing through education,26 as regulation to promote change does not necessarily promote quality. P. Use of antipsychotic drugs in nursing homes: current compliance with OBRA regulations. A policy analysis, Person-centered care for nursing home residents: The culture-change movement, Nursing assistants perceptions of their ability to provide continence care, Medicaid capital reimbursement policy and environmental artifacts of nursing home culture change, Age and sex variation in prevalence of chronic medical conditions in older residents of U.S. nursing homes, Journal of the American Geriatrics Society, The nursing home culture-change movement: Recent past, present, and future directions for research, Overview of significant changes in the Minimum Data Set for nursing homes version 3.0, Indicators of the quality of nursing home residential care. 1-800-273-TALK(8255), Sexual Violence Crisis Line <><><>]/P 110 0 R/Pg 211 0 R/S/Link>> S Deitch R. The limited list of NHS drugs and its effect on their price. Medicaid is a state/federal program that pays for medical services for low-income pregnant women, children, individuals who are elderly or have a disability, parents and women with breast or cervical cancer. A national audit 1995-1998. Before the Nursing Home Reform Act, psychotropic drugs were used widely in US nursing homes. Zimmerman The Eden Model creates a human habitat with continuing contact with plants, animals, and children and also architectural changes (Coleman et al., 2002). OMalley Rovner BW, Edelman BA, Cox MP, Schmuely Y. The Review Committee will determine whether the expenses meet the criteria. http://www.aoa.gov/, National Ombudsman Resource Center (NORC): This information would help nursing homes decide which culture change initiatives to undertake, and strategies to so do. endobj Nursing homes are obligated to meet these standards if they receive Medicare or Medicaid. K. L. <> You have the right to take part in this process. Here you can view a list displaying location specific information for an Ombudsman near you. The impact of nursing home patients on general practitioners workload and prescribing costs. Medicaid is a program that covers medical expenses for certain groups of people who have limited income and resources. Provide services with respect for human . Together, the articles in this supplemental issue of The Gerontologist aim to provide evidence that can be translated into improved practice and policy to transform the culture of nursing home care. . Hepple J, Bowler I, Bowman CE. The following resources were developed by the National Consumer Voice for Quality Long-Term Care, in coordination with the Utah Office of the State Long-Term Care Ombudsman, to assist long-term care providers, ombudsmen, consumers, and other stakeholders in comprehending federal and state requirements around transfer and discharge rights and responsibilities. . . You will need to complete an application and provide some documents, like a birth certificate. Sloane .FI8Jz%>g8$ bop@,V^*m>T0$h@{G;h Family members can also help with your care plan with your permission. Elliot Center for Gerontology and Health Care Research, Brown University, Box G-B213, Providence, RI 02912, USA, Correspondence to: C M Hughes, School of Pharmacy, Queens University of Belfast, Belfast BT9 7BL, Excessive use of psychotropic medication was commonplace in nursing homes in the United States before the Nursing Home Reform Act 1987 was passed, After legislation, psychotropic drugs were used less and a more structured approach to care planning was observed, In the United Kingdom, policy relating to nursing home care is unclear and explicit criteria for quality prescribing have not been formulated, A combination of structured assessment and review of patients, concerted educational interventions, and greater multidisciplinary working may improve long term care in the United Kingdom, Number of drugs used in the previous seven days, Whether new drugs had been started in the previous 90 days, Number of days in the previous seven on which the resident had received injections of any kind. endobj Nursing home (NH) social workers carry out person-centered care, guided by the 1987 Nursing Home Reform Act. By law, nursing homes must develop a care plan for each resident. However, combining structured assessment and review of patients, the introduction of concerted educational interventions, and greater interdisciplinary working may be the best way of improving pharmacotherapy in UK nursing homes. nursing home care and Medicare spent $19.5 billion, for a total of $73.1 billion (Kaiser Commission on Medicaid and Uninsured, 2007). 5 - 7 This practice may have been part of an effort to economise on staff, as larger facilities that employed fewer direct care . Federal law enacted in 1987 as part of the Omnibus Budget & Reconciliation Act of 1987 (OBRA '87) Response to 1986 Institute of Medicine Report titled Improving the Quality of Care in Nursing Homes Abuse/Neglect of Seniors and Adults with Disabilities Use of psychoactive medication and the quality of care in rest homes. An official website of the United States government. This will result in payments being delayed by 1-2 business days depending on your bank's deposit procedures. They deserve better treatment than that currently meted out in NHS long term care. They use this framework to assess the existing literature on culture change interventions in nursing homes and report that published studies do not provide sufficient evidence to guide nursing homes or governing bodies in the implementation of culture change. In the United States, where long term care has undergone dramatic changes in the past 10 years, the quality of care continues to be hotly debated. The present residents of our nursing homes are the very people who fervently supported the NHS from its cradle and believed it would care for them to the grave. Assistive Technology Professional (ATP) Certification Grants. Shortly thereafter, the coalition issued A Consumer Perspective on Quality Care: The Residents Point of View (Holder & Frank, 1985), which informed the work of the Institute of Medicine Committee on Nursing Home Regulation. 1395i-3 & 1396r Nursing Home Reform Act What is it? Expenses must be directly related to the completion of certification criteria and may include, but not limited to: Childcare while the applicant is engaged in, Mileage reimbursement for contact hours when travel exceeds 30 miles one way. Moody Nursing home (NH) social workers carry out person-centered care, guided by the 1987 Nursing Home Reform Act. The prescribing of antipsychotic drugs decreased by about a third after the Nursing Home Reform Act.1820 It was not apparent that one psychotropic drug had been substituted for another, as the reductions in use were accompanied by a small increase in the prescribing of antidepressants and no increase in prescribing of sedative or hypnotic drugs.18 Patients whose documented symptoms before the legislation could be treated appropriately by antipsychotic drugs were less likely to have these drugs stopped.19 It seemed that the reductions resulted from a fall in new users of antipsychotic drugs.20. (a) Advisory Council on Skilled Nursing Facility Rankings under Medicare and Nursing Facility Rankings under Medicaid. (1) E STABLISHMENT.Not later than 1 year after the date of enactment of this Act, the Secretary of Health and Human Services shall establish the Advisory Council on Skilled Nursing Facility Rankings under Medicare and Nursing Facility Rankings under Medicaid (in this . Improvements to Nursing Facilities under the Medicare and Medicaid Programs. Inadequate training in geriatric pharmacotherapy may contribute to poor prescribing in nursing homes.8,27,28 Programmes tailored to the individual have proved to be successful in changing prescribing patterns and are familiar to doctors in the United Kingdom as medical and pharmaceutical advisers have used them to improve prescribing within general practice (the process of academic detailing).29,30 The long term benefits of this approach for doctors, other healthcare professionals, and patients may be much greater.29,30. D. This landmark federal legislation comes by its common name "OBRA" through the legislative process. . A randomized trial of a program to reduce the use of psychoactive drugs in nursing homes. The Commonwealth Fund. <> G. J. Medicaid is a state/federal program that pays for medical services for low-income pregnant women, children, individuals who are elderly or have a disability, parents and women with breast or cervical cancer. Marsteller BRIEF OF AMICI CURIAE AARP, AARP FOUNDATION, CALIFORNIA ADVOCATES FOR NURSING HOME REFORM, THE CENTER FOR MEDICARE ADVOCACY, JUSTICE IN AGING, LONG TERM CARE COMMUNITY COALITION, AND THE NATIONAL CONSUMER VOICE FOR QUALITY LONG-TERM CARE IN SUPPORT OF RESPONDENT AND URGING AFFIRMANCE Semla TP, Palla K, Poddig B, Brauner DJ. Often residents are unable to do it themselves. The Nursing Home Reform Act enforces quality care and the provision of certain services to nursing home residents. Morris J, Hawes C, Fries B, Phillips C, Mor V, Katz S. Designing the national resident assessment system for nursing homes. A randomized trial of a program to reduce the use of psychoactive drugs in nursing homes. 1-801-587-3000, National Suicide Prevention Lifeline For full access to this pdf, sign in to an existing account, or purchase an annual subscription. The Veterans Administration (VA) has launched culture change in its facilities, including changing their terminology and now referring to nursing homes as Community Living Centers (Sullivan et al., 2013). The ability to deliver individualized, high-quality care is impeded by the lack of consistent, well-trained workers, as well as lack of integration across the members of the care team (Cott, 1997; Mather & Bakas, 2002), poor organizational readiness for change, and organizational instability (Berlowitz et al., 2003; Collier & Harrington, 2008). We want the manuals and the Medicaid Information Bulletins to assist you as a Medicaid provider. Cohen Despite the growing recognition that our ageing population represents a major challenge to the provision of health services,1,2 no major government policy initiative had focused on this topic until the recent establishment of a royal commission. 14 0 obj 109 Capitol Street To learn more about the eligibility requirements, click here. Cohen California State University, Long BeachProQuest Dissertations Publishing, 2018. GPs negotiate payment for nursing home patients. Dwyer 171 0 obj TTY: Maine relay 711, Maine Department of Health and Human Services, Older Adults and Adults with Disabilities, Case Mix, Private Duty Nursing, and Home Health, Americans With Disabilities Act/Civil Rights Compliance, Obtaining contact hours required for certification, Attending the prep course to prepare for the exam, Attending coursework required for certification. Introduction Two major sets of Federal regulatory requirements affect nursing homes. S. C. . http://dhs.utah.gov, About Assisted Living: However, reductions in the prescribing of psychoactive drugs are reported to have occurred before the legislation came into effect.1-3,1-4 Furthermore, the legislation was criticised for being restrictive without providing guidelines on alternative drug treatments and, possibly, for leading to negative prescribing habits that were detrimental to some older patients.1-5,1-6. E. C. -W'$RLN K)|~{2Lg)/bI1U4G|cZw'! 2P*@xo$?^?AH=?>q^oG{Q7MF8$80Ng#Dn E ?4GCd\!WhSy(I/6x ?>/g'_{)_pT8w:_:T|/(t4xhh_w0,?ao gb^{~i3!v?cjm$L9CZORy_3_e3?-8Dgbxeg(/Lco1-'yXF!BX0! J. endobj To qualify, these individuals must meet income and other eligibility requirements. We appreciate and consider your suggestions. endobj Nursing homes implementing culture change, Culture change and nursing home quality of care, The effects of changes in nursing home staffing on pressure ulcer rates, Journal of the American Medical Directors Association, Culture change models and resident health outcomes in long-term care. What does the evidence really say about culture change in nursing homes? Also requires that the HHS Secretary, within 18 months after enactment of this Act, issue guidance for personnel of nursing homes enrolled in the Medicare or Medicaid . Providers should be aware that due to system rate update, the PRISM claim adjudication cycle scheduled for June 23, 2023 is postponed one day until June 24, 2023. Their framework moves to clarify the labels surrounding the discussion of quality, emphasizing that residential quality and quality of care should combine to enhance quality of life. Frail older patients were systematically removed from the care of consultant geriatricians and gravitated on to general practitioners lists as the number of long stay beds in hospitals withered in the wake of burgeoning development of private sector nursing homes. uuid:8e8d1504-aef6-11b2-0a00-20bd82010000 endobj Coleman Ziegler Overworked, undertrained, and sometimes unenthusiastic general practitioners have tried to pick up the pieces ever since.1-10 Older patients in nursing homes often need intense specialist care that general practitioners are often poorly equipped and inadequately remunerated to provide. N. Certified Ombudsman not only visit residents, investigate and resolve complaints, but also use their skills to advocate for the rights of residents in nursing homes and other long term care facilities. Grants of up to $2,000 will be awarded to up to 10 applicants to support their completion of the ATP certification requirements. This bill requires the Centers for Medicare & Medicaid Services (CMS) to establish a ranking system and related programs for Medicare skilled nursing facilities and Medicaid nursing facilities, taking into account the findings and recommendations of a specified advisory council. Many states also include residents' rights in state law or regulation. endobj C. Elliot But some recent reports and congressional hearings indicate there are still concerns about quality of care. Bishop (2014) examines culture change in the context of high-performance work systems, drawing on insights from other sectors to consider similarities and differences regarding staffing recommendations. Before the Nursing Home Reform Act, psychotropic drugs were used widely in US nursing homes.46 These drugs were prescribed for 43%-55% of patients in homes, despite the lack of documentation justifying their use.57 This practice may have been part of an effort to economise on staff, as larger facilities that employed fewer direct care personnel per bed were more likely to have high rates of psychotropic drug use.4. Department of Geriatric Medicine, St Georges Hospital Medical School. <>stream E. J. Efforts to shift to a broader focus on overall quality of life and well-being face several serious challenges. Please access the current PDF manuals temporarily. S. S. Secretary must develop methods to separately track reports of confirmed incidents of nursing home abuse or neglect in survey forms submitted by nursing homes through that system. Not surprisingly, the rearguard action of general practitioners to provide medical support to nursing homes is under increasing strain, culminating in growing calls to exclude nursing home patients from the terms of their contract to provide general medical services.1-11, The investment of skill and time to remedy healthcare problems in UK nursing homeswhether through prevention, assessment, treatment, or rehabilitationcannot be left to beleaguered general practitioners. Please report. Better known as OBRA 1987, this law set Federal standards for the qual-ity of services for staffing and for inspection and oversight of long-term care facilities. Shwartz These list commonly used antipsychotic drugs covered by the regulation (for example, chlorpromazine, thioridazine, and haloperidol) and their corresponding proper indications (for example, schizophrenia) and improper indications (for example, non-cooperation) for use. The Green House model most notably stresses architectural changes to promote elder-centered care in small homes; care is provided by a self-directed team that is responsible for all care and meal preparation, and collaborative decision making, resident-directed care, and close relationships between staff and residents are emphasized (Zimmerman & Cohen, 2010). Right to a Dignified Existence . To access all your records and reports, including clinical records (medical records and reports) promptly (on weekdays). In addition, nursing homes are a workplace for more than 900,000 nursing staff (Jones, Dwyer, Bercovitz, & Strahan, 2009), where turnover is a common occurrence and related to poorer resident outcomes (Castle & Engberg, 2005; Collier & Harrington, 2008; Hickey et al., 2005). This article briefly reviews the history of culture change, discusses some of the challenges related to culture change in nursing homes, and overviews the conceptualization and select models of culture change. M Strahan Moskowitz Crisis Line & Mobile Outreach Team Cohen E-mail: Search for other works by this author on: UCLA/JH Borun Center for Gerontological Research, VA GLAHS GRECC and HSR&D Center of Innovation, RAND Corporation, Advancing Excellence in Americas Nursing Homes, Quality improvement implementation in the nursing home, Building a state coalition for nursing home excellence, High-performance workplace practices in nursing homes: An economic perspective, Implications for policy: The nursing home as least restrictive setting, Developing the Green House nursing care team: Variations on development and implementation, Staff turnover and quality of care in nursing homes, Centers for Medicare & Medicaid Services (CMS), Staffing characteristics, turnover rates, and quality of resident care in nursing facilities, The Eden Alternative: Findings after 1 year of implementation, We decide, you carry it out: A social network analysis of multidisciplinary long-term care teams, A recipe for culture change? 1 0 obj MDS 3.0: Can this release be all things to all people? Recognizing these challenges, stakeholders have begun to emphasize the restructuring of how nursing homes view and deliver care (Saliba & Schnelle, 2002). Embracing this more comprehensive perspective, some of the better known models of culture change include the Wellspring Model, the Eden Alternative, and more recently the Green House Model. Residents of nursing homes have rights that are guaranteed by the federal Nursing Home Reform Law. . nursing home residents' ability to enforce, via Section 1983, the rights codified in the Federal Nursing Home Reform Act, which is consistent with Congress' intent in drafting and passing that legislation.3 3 Indeed, in 1987, Senator Wydenthen serving as a United States Representative on the House of Representatives Avorn JL, Dreyer P, Connelly K, Soumerai SB. Shown Here: Introduced in Senate (03/16/2021) Nursing Home Reform Modernization Act of 2021. 10785046. As an Ombudsman: Participate in efforts to maintain and promote the integrity of the long-term care Ombudsman program. Are you interested in using your time and talents to serve as an advocate for nursing home and adult care facility residents? <><><>]/P 125 0 R/Pg 215 0 R/S/Link>> Nolet 184 0 obj Beardsley RS, Larson DB, Burns BJ, Thompson JW, Kamerow DB. Kolanowski HHS Vulnerability Disclosure, Help The purpose of this literature review was to Young 2020-07-27T07:04:52-07:00 Saliba D N. H. For questions, email, Abuse/Neglect of Seniors and Adults with Disabilities. The impetus for changes in the long term care system includes legislation and regulation in the form of the Nursing Home Reform Act of 1987. In preparing for the supplemental issue, potential authors were invited to contribute papers based on their expertise in the field. The views presented here are those of the authors and not necessarily those of the Commonwealth Fund, its directors, officers, or staff. 221 0 obj Many residents experience transfer trauma, also known as relocation stress syndrome. Code of Ethics. Saliba It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. Pursuant to U.S. Sup. Manuals. Shier and colleagues (2014) begin by providing a useful framework to consider factors influencing culture change and its outcomes. The act was first implemented by the U.S. Congress in 1987. Pbs9dA/d3StyDhhbSDrofg==:KwsszaN2tvM3sLEeCE4XME+r6o8++9Y029kthwNiPPHUXkm7kBPIYs70DAB+rhLEFUF8zTVJ/HE1Y2BOsQv46JegQ87He5Wa7pHkAh2hdEjCyjRmHMvgsGaGfpfwONXbFr8guOuwUjRPxsjc16vzyI3xKUvPFF2+obrlkt4qUU7A3Dg+mr9X9pa5R28p581uuwCjLD3o3VYXbc6ScTSJK4e+9TK8WIedyYBv9udMaziYrwSNDVuwbPg/3GBjtDwL2Okw41F2dcnkn2aoMQF8ZkFho7MwADV4/AqKwTSuj8a0KIyzsSMi9Y0W14tKSGP+m+3JLkS25MO8sKSqrL59zCuLlIEC3uzEw+ycWpUBaSwLklfjZPVukCltf9IbbHtQVE2YPMAVUmYb4qGbwDD+6w==. Steinman YZ |7r. The goal of the act is to ensure that seniors in nursing homes receive high quality care. Avorn J, Soumerai SB, Everitt DE, Ross-Degnan D, Beers MH, Sherman D, et al. Intersections of ageism and homelessness among older adults: Implications for policy, practice, and research, Age is But a Number: Hippie Lessons on Commitment, Life, and Death, Climate Change Policies and Older Adults: An Analysis of States Climate Adaptation Plans, Live Gerontology: Understanding and Representing Aging, Loneliness, and Long-Term Care through Science and Art, About The Gerontological Society of America, Conceptualization and Models of Culture Change, Moore, Boscardin, Steinman, & Schwartz, 2012, Hill, Kolanowski, Milone-Nuzzo, & Yevchak, 2011, Shier, Khodyakov, Cohen, Zimmerman, & Saliba, 2014, Elliot, Cohen, Reed, Nolet, and Zimmerman (2014), Zimmerman, Sloane, Cohen, and Barrick (2014), Grabowski, Elliott, Leitzell, Cohen, and Zimmerman (2014), Beck, Gately, Lubin, Moody, and Beverly (2014), http://www.nhqualitycampaign.org/star_index.aspx?controls=eightgoals, http://dx.doi.org/10.1111/1475-6773.00105, http://dx.doi.org/10.1097/01.mlr.0000163661.67170.b9, http://205.207.175.93/HDI/TableViewer/tableView.aspx?ReportId=521, http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityImprovementOrgs/index.html?redirect=/QualityIMprovementOrgs/04_9thsow.asp#TopOfPage, http://dx.doi.org/10.3928/00220124-20091301-03, http://dx.doi.org/10.1093/gerona/57.7.M422, http://dx.doi.org/10.1016/S0277-9536(97)00066-X, http://dx.doi.org/10.1016/j.jamda.2004.12.003, http://dx.doi.org/10.1111/j.1547-5069.2010.01379.x, http://www.cdc.gov/nchs/data/series/sr_13/sr13_167.pdf, http://dx.doi.org/10.1377/hlthaff.2009.0966, http://dx.doi.org/10.1067/mgn.2002.123788, http://dx.doi: 10.1111/j.1532-5415.2012.03909.x, http://dx.doi.org/10.1093/geront/48.2.142, http://dx.doi.org/10.1016/j.jamda.2012.06.001, http://dx.doi.org/10.1046/j.1532-5415.2002.50366.x, http://dx.doi.org/10.1097/00005650-200411000-00002, http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2002/Aug/Evaluation%20of%20the%20Wellspring%20Model%20for%20Improving%20Nursing%20Home%20Quality/stone_wellspringevaluation%20pdf.pdf, Receive exclusive offers and updates from Oxford Academic, DIRECTOR, CENTER FOR SLEEP & CIRCADIAN RHYTHMS, Academic Pulmonary Sleep Medicine Physician Opportunity in Scenic Central Pennsylvania, Copyright 2023 The Gerontological Society of America.
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